Pre Clinical and Clinical study on Azhal Keel Vayu

NATIONAL INSTITUTE OF SIDDHA Chennai – 47

The Tamil Nadu Dr. M.G.R. Medical University, Chennai – 32

PRE CLINICAL AND CLINICAL STUDY ON

AZHAL KEEL VAYU

(DISSERTATION SUBJECT)

For The Partial Fulfillment Of The Requirements To The Degree Of

DOCTOR OF MEDICINE (SIDDHA) BRANCH I - MARUTHUVAM

2010-2013

ACKNOWLEDGEMENT

My Heartful thanks to SIDDHARS for their blessings and guidance to complete this dissertation.

In all humility, I salute with great thanks to The Tamil Nadu Dr.M.G.R Medical University and Dept of AYUSH, Ministry of Health and Family Welfare, Govt of India for granting permission to take this study.

It’s with enormous pleasure that I expressed my heartful gratitude to Prof.Dr.K.Manickavasakam M.D(S), Director and Head of the Department of Maruthuvam, National Institute of Siddha, Chennai-47 for his valuable guidance and support.

I express my sincere thanks to Chairman and Members of Institutional Ethical Committee (IEC) and Institutional Animal Ethical Committee (IAEC), National Institute of Siddha, Chennai-47, for their valuable guidance.

I express my sincere thanks to Prof.Dr.M.Murugesan,M.D(S), Former Dean, National Institute of Siddha, Chennai-47, for his guidance.

I express my sincere thanks to Prof.Dr.R.S.Ramaswamy, M.D(S), Former Hospital Superintendent, for granting permission to carry out the clinical study in OPD & IPD of National Institute of Siddha, Chennai-47.

I express my sincere thanks to Dr.M.Rajasekaran M.D(S), H.O.D i/c and other Faculties, Department of Gunapadam, National Institute of Siddha, Chennai, for their valuable guidance in the preparation of the trial drug.

I express my deep sense of gratitude to Dr.T.Lakshmikantham M.D(S), lecturer NIS for her valuable guidance and support.

I express my sincere thanks to Dr.H.Vetha Merlin Kumari M.D(S) lecturer NIS for her valuable guidance and support.

I express my heartful thanks to Dr.H.Nalini Sofia M.D(S) lecturer NIS for her memorable support and encouragement.

I express my sincere thanks to Dr.G.Subburagavalu, M.D., Asst. Professor, Department of General Medicine, Madras Medical College, Chennai, for his suggestions for my study.

I acknowledge my thanks to Dr.V.Subha, M.Pharm, Ph.D Assistant professor, pharmacology,NIS for her guidance and support in Toxicological studies.

I express my thanks to Dr. M.Muthuvel, Assistant professor, Biochemistry, National Institute of Siddha, Chennai-47, for his guidance and support in Biochemical analysis.

I express my sincere thanks to Dr. D.Aravind, M.D(S), M.Sc.,[Medicinal plants], Assistant professor, Medicinal Botany, National Institute of Siddha, Chennai guidance in botanical identification and authentication.

I express my sincere thanks to Mr.M.Subramanian M.Sc. (Statistics) Senior Research Officer, National Institute of Siddha, for his guidance in preparing the protocol and statistical analysis.

I extend my sincere thanks to Dr.R.Murugesan, scientific officer Gr-I SAIF, IIT, Chennai-36, for conducting the ICP and SEM analysis and detecting trace metals of the trial drug.

I wish to thank the staffs of library, technicians of the clinical pathology laboratory and Bio-Chemistry Department, National Institute of Siddha, Chennai.

I like to thank all my patients who have given their consent to record their case materials and for their co-operation.

I take this opportunity to thank my family and friends for their Co-Operation and Moral support from the very beginning of my career.

SL NO

CONTENTS ^P.NO

1 Introduction 1

2 Aim and Objectives 5

3 Review of Literature 7

a. Siddha Aspects 8

b. Modern Aspects 43

c. Properties of trial drug 56

4 Materials and Methods 66

a. Pre Clinical study 67

b. Protocol 79

c. Preparation of trial drug 92

5 Observation and Results 98

6 Discussion 133

7 Summary 141

8 Conclusion 144

9 Annexure - I ( Toxicological studies ) 147 10 Annexure - II ( Biochemical analysis ) 162

11 Annexure - III( Certificates ) 173

12 Annexure - IV (Proforma ) 180

13 Bibliography 208

Introduction

INTRODUCTION

Siddha system of medicine is the oldest among the Indian systems of medicine founded by siddhars and is also known as Tamil maruthuvam .

The origin of the siddha system dates back to BC 10,000- BC 4000, according to Thiru T.V Sambasivam pillai siddha medical dictionary.

The word ‘siddha’ comes from the word ‘siddham’ Siddha means ‘knowledge or wisdom’

Siddham means an object to be attained on perfection or ‘heavenly wisdom’

One who had attained perfection in life is called ‘siddhar’.

Siddhars were indeed true scientists who discovered and displayed god to the common people through their divine wisdom, medicines and elixirs with which they treated the incurable diseases of mankind.

Siddhars prepared varieties of medicines such as Parpam, Chenduram, Pathangam,Kattu, Kalangu, Chunnam, Satthu, Guru kuligai etc..From herbs,metals,minerals and animal products.

Siddha system is holistic system of medicine which treats individual both spiritually and physically. The treatment varies for different individuals based on their physical constitutions (Prakriti)

Siddha system of medicine classifies disease into 4448 types .According to this system of medicine , the human body is made up on three humours – vali, Azhal, Iyyam .In normal healthy condition ratio between them being 1:1/2:1/4.

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When the normal ratio of these humours – Vali, Azhal, Iyyam is disturbed, disease will occur.

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The factors which affect this equilibrium are environment, climatic conditions, diet and abnormal physical activities etc.

As per yoogi vaithiya sinthamani vatha disease is classified as 80 types. One such type is keelvayu otherwise called as Santhuvatham. As per sabapathy kaiyedu keelvayu is further classified into 10 types. One such type is Azhal keel vayu.

As per sabapathy kaiyedu Azhal keel vayu is a disease with the symptoms of pain and swelling in the knee joints, fever difficulty in walking etc…it has the correlation with Osteoarthritis(OA) of modern science.

There are many diseases commonly affecting the middle aged and elderly people. One among them is Osteo arthritis which is given importance as it is mainly interfering with the principal function of human beings (i.e) locomotion.

The prevalence of OA in India is very high. The distribution of OA in men and women is similar. The prevalence of osteoarthritis between the age of 40-65 is 68% Approximately 4 out of 100 people are affected . Before age 45 more men have it, while after age 45 it is more common in women.60% of women are affected.

Menopausal women are particularly prone to it.

Hence the author is interested to try effective remedy to this patients as said in Siddha literatures which the application of basic principles of Siddha and also supporting by modern parameters

The medicine chosen to this disease are Sarva noi Linga Chenduram (Internal) (Ref- Anuboga Vaithiya Navaneetham , Part 4,Hackim PA. Mohammed Abdullah Sayubu , Edition: pg no 52 &53 and Maasha thylum (External) (Ref- Vaithiya Sinthamani ( Sigicha Rathina deepam Pg no:2C.Kannusamipillai Edition 2007

As per siddha text book the above said siddha formulations are found to possess antivatha property. They would be cost effective, efficacious and easy to prepare.

Aim and

Objectives

AIM AND OBJECTIVES

AIM

The principal aim of the present study is

 To evaluate the therapeutic efficacy of the Siddha formulations sarva noi linga Chenduram (Internal) and Maasha thylam (External) in the treatment of Azhal keel vayu (Osteo arthritis).

OBJECTIVES

PRIMARY OBJECTIVE

To evaluate the therapeutic efficacy of the Siddha drugs sarva noi linga Chenduram (Internal) and Maasha thylum (External) in reducing the pain in Azhal keel vayu (Osteo arthritis).

SECONDARY OBJECTIVE

To conduct a clinical trial with a well defined proforma on the patients identified with “Azhal keel vayu ”.

To evaluate the safety of the test drugs (Acute and Sub acute toxicity studies) to be carried out as per WHO guidelines.

To study the influence of other co factors such as age, sex, dietary habits, family history, socio economic status, habitat etc on the disease.

To study Azhal keel vayu on the basis of

(a) Mukkutram (b) Udalkattugal (c) Envagai thervugal etc To find out the side effects / adverse effects of the drug “SARVA NOI LINGA CHENDURAM (Internal) and MAASHA THYLUM (External)” if any.

To screen the biochemical constituents of the drug.

Review of

Literature

Siddha Aspects

LITERATURE REVIEW

SIDDHA ASPECTS

Universe originally consisted of atoms which contributed to the five basic elements (pancha boothas) namely Earth, water, fire, air, and ether which corresponds to the five sense of the human body and they were the fundamentals of all human body and all the corporal things.

The food we eat has six tastes namely sweet, sour, salt, bitter, pungent and astringent. Each of them is a mixture of five basic elements

- - + - + - + - + - + - +

Pancha poothas are the foundations for three humours (vaatham, piththam, kabam) which are the pillars that support our body structure.

Vaayu + Aagayam constitute vaatham Theyu constitute piththam

Appu + Mann constitute kabam

Any alterations in the level of three humours affects the normal functions of the body.

AZHAL KEEL VAAYU

In Siddha literature Azhal keel vaayu described under vatha diseases.

Keel vaayu is the general term that includes all kinds of joint disorders.

Description of the nomenclature

Azhal keel vaayu = Azhal + Keel + Vaayu Azhal = Pitham

Keel = Joint Vaayu = Vatham

Initially the joint is affected by the vitiated vatham. Pitham and kabam accompany later. It is a disease which is common in pitha kaalam (middle 1/3 of the lifespan).

TYPES OF KEEL VAAYU

Azal keel Vaayu is one among the ten types of Keel vaayu, which is mentioned in the text Siddha Maruthuvam, the ten types of Keel vaayu are:

1. Vali keel vaayu 2. Azhal keel vaayu 3. Iyya keel vaayu

4. Vali Azhal keel vaayu 5. Vali Iyya keel vaayu 6. Azhal Vali keel vaayu 7. Azhal Iyya keel vaayu 8. Iyya Vali keel vaayu 9. Iyya Azhal keel vaayu 10.Mukkutra keel vaayu AETIOLOGY

SEASONAL FACTORS:

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It is said that the vatha diseases are precipitated in the months from Aani to Karthigai (June to December), hence the seasonal factors are involved and facilitate the vatha diseases.

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In muthuvenil kalam the increased solar radiation increases the evaporation of water content from the body in turn increases the kabam and vatham thathus resulting in the production of vali diseases.

DIET

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Vatha disease is caused due to the following reasons:

Excessive intake of tubers Excessive intake of chill foods Wandering in chill air

Getting drenched in rain Living in hilly region

Excessive sexual desire and Heredity

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Excessive intake of bitter,pungent, astringent and acrid taste food, intake of varagu, thinai and altered sleep pattern also contribute to vatha disease.

In Agathiyar kanma kaandam..,

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According to Agathiyar kanma kaandam, cutting young trees and fracturing the legs of animals will produce Vatha diseases.

VATHA DISEASES

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As per Theraiyar, Vatham is being hailed as the king, who rules the fort (Body) and enables the dwelling of the citizen (Uyir) in the fort. Hence Theraiyar lauds Vatham as the prime force in normal state.

HABITS_:

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The factors like, walking under hot sun, increased sexual desire, and excessive in take of water and bitter guard etc, also disturbs the normal functions of Vaatham.

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Excessive intake of bitter, astringent, pungent taste, excessive intake of food, intake of rain water, altered sleep rhythm, increased starvation and increased sexual desire will produce vatha diseases.

CHARACTERS OF VATHA DISEASES_:

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When vatham increases gsses increases, many diseases may arise like sanni, body loses the weight.

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When the Vatha kutram aggravates it will produce the following signs and symptoms:

loss of appetite, Excruciating pain Fever

Cough,

Insomnia

Shivering of the body Nervous weakness Joint pain

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According to Agathiyar vaithiya Kaaviyam, the deranged vali produces pain in the joints of the hands and legs, flatulence, constipation, scanty micturition, fever with rigor, generalized body pain and increased sweating.

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According to Theraiyar vagadam, the deranged vali produces pain in the joints, head ache, constipation, increase salivation, fever with rigor and loss of normal complexion.

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According to Theraiyar karisal, the deranged vali produces blackish discolouration of body, feverishness, increased sweating, indigestion and dyspnoea.

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1000 According to Agathiyar vatha Kaaviyam 1000, the deranged vali produces abdominal discomfort, pain in joints, oliguria, dysuria, constipation and flatulence.

SITES OF VALI

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The sites of vali

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According to vaithiya sathagm, vatham dwells in the following places: Umbilicus, rectum, faecal matters, abdomen, anus, bones, hipjoints, skin, navel plexus,Joints, Hair follicles and muscles.

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According to sage Thirumoolar and sage Yugi, the places of vatham are the anus and below the navel region.

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According to Anupoga vaithiya bramma ragasiyam, vatham exists between the umbilicus and navel region.

Properties of Vali:

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Natural properties of Vatham: [Ref: Noi Nadal part-1]

1. Giving briskness

2. Expiration and Inspiration

3. Functioning of the mind, thoughts and body

4. Regulation of the “Fourteen Physiological Reflexes”(Vegam).

5. Functioning of the “Seven Udal Kattukal” uniformly

6. Protection and strengthening of the five sensory organs. (Iymporigal)

Symptoms of Vatham thodam:

1. Body ache 2. Pricking pain 3. Tearing pain 4. Nerve weakness 5. Mental distress 6. Movements 7. Joints pain 8. Traumatic pain 9. Dislocation of joints 10. Weakness of organs 11. Paralysis of limbs 12. Polydypsia

13. Severe pain in calf and thigh muscles 14. Bony pricking pain

15. Anuria and constipation

16. Unable to do flexion and extension of the limbs 17. All tastes to be like astringent

18. Excess Salivation

- Rough

- Dry

- Light

- Cold

- Unstable

- Subtl

- Soft

- Unctuous

- Heavy

- Hot

- Stabl

- Solid

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In Azhal keel vayu

NAME LOCATION PHYSIOLOGICAL FUNCTIONS Abanan Lower abdomen

and Extremities

Responsible for urination, defecation and parturition, Menstruation, ejaculation of the sperm.

Viyanan Heart Responsible for movements of all parts of the body and sensation.

Samanan Stomach Responsible for proper digestion

Abanan is affected and so constipation is produced.

Viyanan is affected it renders difficulty in movements of the knee joints.

Samanan is also affected because disturbed state of other vaayus

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It is characterized by swelling of joints associated with severe pain and pyrexia. Since it is not quickly responding to medicine the prolonged medical care is said to be essential. As pitha increases kaba (mucous) in the joint decrease and hence dryness occur. So, during flexion of the joint crepitation is produced

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- Diagnosis in Siddha:

Piniyari muraigal (Method of Diagnosis) is based upon three main principles, 1) Poriyal Arithal(Inspection)

2) Pulanal Arithal (Palpation) 3) Vinaathal(interrogation) 1. Poriyal Arithal (Inspection

):

“Poriyal arithal” means examining the “Pori” of the patient by the

“Pori” of the physician for proper diagnosis. Pori is considered as the “Five sense organs” of perception namely,

1) Mei (Skin) 2) Vai (Tongue) 3) Kan (Eye) 4) Mookku (Nose) 5) Sevi (Ear) 2. Pulanal arithal (Palpation):

Pulan are five object of senses. They are, 1) Smell

2) Taste 3) Vision

4) Sensation of touch 5) Hearing

“Pulanal arithal” means examining the “Pulan” of the patient by the “Pulan” of the Physician to diagnose a disease.

3.Vinaathal (Interrogation):

Vinaathal is gathering information regarding the history of disease, its clinical features etc., from the patient or his/her close relatives useful when the patient is not in a position to speak or in the case of a child.

ENN VAGAI THERVUGAL (Eight diagnostic Tools):

It is a unique method of diagnosis in Siddha system of medicine. They are clearly explained by Siddhar Theraiyar

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Hence the diagnosis is made by the following 1. Naadi (pulse)

2. Sparisam (sensation to touch) 3. Naa (tongue)

4. Niram (colour) 5. Mozhi ( voice) 6. Vizhi (eyes) 7. Malam ( faeces) 8. Moothiram (urine)

Azhal keel vayu in relation with Envagaithervugal,

NAADI :

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Naadi is responsible for existence of life and can be felt one inch away from the wrist joint on radial side by means of palpation with the tips of index, middle and ring fingers corresponding to vaatham, pitham, kabam respectively.

The three humors vaatham, piththam and kabam exisits in the ratio 1:½ :¼ normally. Derangement in these ratios leads to various disease entities.

The three “ uyir thathukkal’’ are formed by the combination of three nadigal with three vaayu.

a) Edakalai + Abaanan = Vaatham

b) Pinkalai + Piranan = Piththam

c) Suzhumunai + Samanan = Kabam

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When piththa gets vitiation it accompany with vatha and causes pain in every joints.

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When kapha and vatha are vitiated pain occurs in the nerves and lower extremities.

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When vatha gets vitiation pain occurs in the joints and lower extremities.

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When kapha vitiated with vatha, it causes pain and swelling in the joints.

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When piththa vitiated with kapha it results in stabbing pain in bones and joints.

In Azhal Keel Vayu the following types of naadi can be seen commonly.

They are,

a ) vaatha piththam b ) vaatha kabam c ) piththa vaatham d ) piththa kabam e ) kaba vaatham

2. Sparism (Sensation to touch):

In Azhal keel vaayu mild warmth noticed over the affected joint.

3. Naa (Tongue):

In Azhal keel vaayu no abnormality is seen in Naa.

4. Niram(Colour):

In Azhal keel vaayu no abnormality is seen in Niram.

5. Mozhi:

It constitutes high, low-pitched voice, nasal speech, hoarseness of voice slurring and incoherent speech etc.

In Azhal keel vayu no abnormatlities are seen normally.

6. Vizhi:

Both motor and sensory disturbance of eye are noticed. Redness of eyes, paleness, excessive lacrimation, swelling, corneal ulcers, sunken eyes may be noted for.

In Azhal keel vayu no abnormatlities are seen normally. In anaemic patients pale conjunctiva may be noted.

7. Malam:

Vatha type: Black coloured stools with constipation.

Pitha type: Loose stools with yellowish red colour Kabha type: White coloured stools with mucous

Thontha type: Stools possess some of the features of two thodams In Azhal keel vayu constipation was reported in some of the cases.

VIII. Moothiram:

Neerkuri and Neikuri (Oil on urine sign) are special diagnostic methods regarding urine (Moothiram).

Neerkuri and Neikkuri:

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Prior to the day of urine examination the patient is instructed to take a balanced diet and quantities of food must be proportionate to his routine intake. The patient could have no disturbed sleep. After waking up in the morning, the first urine

voided is collected in a clear wide mouthed glass bowel and is subjected to analysis of

“Neerkkuri and Neikkuri” within one and a half an hour.

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Voided urine has the following characters 1. Niram - Colour

2. Edai - Specific Gravity 3. Manam - Smell

4. Nurai - Frothy nature 5. Enjal - Deposits

Apart from these , the frequency of urination , abnormal constituents , such as sugar, protein, presence of blood, pus, also to be found out.

In Azhal keel vayu patient straw coloured urine was noticed.

Neikuri:

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The process of dropped gingely oil indication

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The collected specimen was examined by the following method. The collected urine specimen is kept in a glass bowel and observed under direct sunlight without shaking the vessel. Then drip one drop of gingely oil and observe the spreading pattern and concludes as follows

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When the oil drops lengthens like a snake it indicates ‘vatha Neer’

When the oil drops spreads like a ring it indicates ‘pitha Neer’

When the oil drops remains that of pearl it indicates’ kaba Neer’

PARUVAKAALAM (Seasonal variations):

S.No STATE OF KUTTRAM KAALAM

1. Vatham thannilai adaithal

Munpani kaalam, Pinpani

kaalam,Koothir kaalam, Elavenil

kaalam

2. Vatham thannilai valarchi Muthuvenil kaalam 3. Vatham vetrunilai

valarchi

Kaarkaalam

Vatham vitiates during Muthuvenil, i.e during summer, the environment is hot it leads to dryness of the body and the body loses its energy through perspiration and may impair the digestion.

So, in Azhal keel vayu the disease shows its exacerbation during muthuvenil kaalam.

THINAI (Geographical Distribution):

It is divided into five types. They are,

S. NO THINAI LAND AFFECTED

HUMORS 1. Kurinchi Mountain and its surroundings

Hilly terrain Kabam

2. Mullai Forest and its surroundings

Forest ranges Pitham

3. Marutham Farm land and its surroundings Cultivable lands

All three humors are in equilibrium 4. Neithal Sea shore and its adjoining areas

Coastal belt Vatham

5. Palai Desert and its surroundings Arid zone

All three humors are affected.

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Geographical distribution plays a vital role in altering Mukkutrams.

According to Siddha, vatha diseases are predominant in Mullai and Neithal Thinai.

UDAL KATTUGAL:

Our body consists of seven udal kattukal.

SL.

No

UDAL

KATTUGAL FUNCTIONS

1. Saaram It gives strength to the body and mind.

2. Senneer Saaram after absorption is converted into senneer. It is responsible for knowledge strength, boldness and healthy complexion.

3. Oon Gives structure and shape to the body and is responsible for the movements of the body.

4. Kozhuppu Lubricates the organs on its own works.

5. Enbu Protects the vital organs and used for movements and nominates the body structure.

6. Moolai Present inside the bones and it gives strength and maintains the normal Condition of the bone.

7. Sukkilam(or)

suronitham

Responsible for the reproductive function of species.

S.no UDAL

KATTUKAL INCREASED CONDITIONS DECRESED CONDITIONS 1 Saaram Loss of appetite, excessive

salivation,diminished activity, heaviness, pallor, cold, decreased physical constituents, dyspnoea, flatulence, cough, excessive sleep.

Tiredness,dryness of skin, Laziness, loss of weight, lassitude, and irritability while hearing heavy noise.

2 Senneer Boils and tumours in different Parts of the body,

Spleenomegaly,

pricking pain, increased blood Pressure, reddish eye and skin,

jaundice, leprosy, haematuria etc.

Affinity to sour and cold food, nervous debility, dryness , pallor.

3 Oon Tubercular adenitis, Tumours or extra growth around the neck, cheeks, abdomen, thigh, genitalia.

Lethargic sense organs, pain in the joints, muscle wasting in mandibular region, gluteal region, penis, thighs.

4 Kozhuppu Identical feature of increased flesh, tiredness, dyspnoea on exertion, extra musculature in gluteal region, external genetalia, chest, abdomen thighs

Loins Pain, spleenomegaly, emaciation.

5 Enbu Excessive ossification and dentition

Joint pain, falling of teeth, falling and splitting of hairs and nails.

6 Moolai Heaviness of the body and eyes, swollen inter phalangeal joints, oliguria and non healing ulcers.

Osteoporosis, Blurred vision.

7 Sukkilam or Suronitham

Increased sexual activity and signs identical to urinary calculi

Dribbling of sukkilam/

suronitham or senneer during coitus, pricking pain in the testis, inflammed and contused external genitalia.

In Azhal keel vaayu,

Saaram, Kozhuppu, Moolai and Enbu thathukkal are commonly affected.

Saaram : Weakness, pain in knee joints

Kozhuppu : Morning stiffness occurs in affected knee joints

Enbu : Pain occurring in affected knee joints, crepitations present Moolai : Osteoarthritis in knee joints

UYIR THATHUKKAL:

Human body is influenced by three uyir thathukkal i.e, Vatham, Pitham and kabam. They are responsible for normal physiological conditions of the body.

Vatham

DESCRIPTION OF VATHAM:

The Siddha classical texts divide the general principles of Vatham into ten subsidiary forms that differ from one another by their localizion in the body (Anatomical) and by their particular functions (Physioloical). They are

1. PRAANAN: (Heart Centre)

It refers to be in the chest. It maintains the action of the heart, the functioning of the mental faculties of perception and concentrations and also cares for the arteries, veins and nerves. It regulates the respiration and digestion. It is otherwise called as

“Uyirkkaal”.

2. ABAANAN: (Moolaadharam Centre)

It corresponds to the pelvic area and controls the excretion. It is focussed in the lower part of the gut and also occupies the sites in the bladder and genitals. It has a tendency to travel downwards. It moves in the whole Genito Urinary Tract and regulates the defaecation, micturition, menstruation, parturition and ejaculation. It is otherwise termed as “Keezhnokkumkaal”.

3. VIYAANAN: (Fore head Centre)

It corresponds to the naso cilary area i.e at the root of the nose and base of the skull and controls the will. It helps in the circulation of energy throughout the entire nervous system and the movements of various parts of the body. It also transports nutrients and blood throughout the entire body. It is also known as

“Paravukaal.”

4. UDHAANAN: (Throat Centre)

This corresponds to the pharyngeal area in the throat region and controls speech and breathing. It is also responsible for the physiological reflex actions like vomiting, hiccup, cough, etc. It has the tendency to travel upwards. It is otherwise named as “Melnokkukaal.”

5. SAMAANAN: (Navel Centre)

It corresponds to in the navel region and controls digestion. It selects the useful substances from the swallowed food and supplies them to the whole body. It balances the other ‘Vayus” it is also called “Nadukkaal.”

6. NAAGAN:

It is responsible for the intelligence of an individual, winking, singing and pilo erection.

7. KOORMAN:

It is responsible for yawning, closing of mouth (movement of lower jaw) winking, shedding of tears, vision and opening of the eyes.

8. KIRUGARAN:

It is responsible for salivation and nasal secretion. It helps in digestion and meditation. It produces cough and sneeze.

9. DHEVATHATHAN:

It is responsible for laziness, lassitude, quarreling, arguing, and also for much anger. It helps movements of the eyeball in various directions and is present in genital and anal region.

10. DHANANJEYAN:

It is present in nose and responsible for swelling of the body and tinnitus. It leaves the body by blowing up the cranium only on the third day after death.

[Ref: Siddha Maruthuvanga Churukkam]

Piththam

Piththam is responsible for all the transformation. piththam is located in urinary bladder,heart, umbilicus,abdomen,blood, sweat, skin and eyes.

Piththam is classified into 5 types.

1.Anala piththam - Responsible for digestion of food 2.Ranjaga piththam - Responsible for colour of blood 3.Sathagam - Located in heart and is responsible for

normal activities of the body.

4.Alosagam - Responsible for normal vision

5.Prasagam - Responsible for the complexion of skin In Azhal keel vayu

Sathagam affected- Difficulty in walking, climbing upstairs, squatting, sitting cross legged (Daily activities).

Kabam

Stabilizes, maintain and lubricates the joints and helps in their movements.

Kabam is found in samanan, semen, brain, head, tongue, nose, bones, bone marrow, fat, nerves, chest, blood, large intestine, eyes, stomach and pancreas.

Kabam is clasiified in to 5 types they are

1. Avalambagam- Heart is the centre for avalambagam. It controls all other Forms of kabam.

2.Kiletham- Stomach is the center for kiletham. It give moisture and Softness to the ingested food and helps digestion.

3. Pothagam- Tongue is the center for Pothagam and it is responsible for the sense of taste

4. Dharpagam - Head is the center for Dharpagam. It gives cooling effect to eyes

5. Santhigam- It lies in the joints and it is responsible for the locomotive action of movable bony joints.

In Azhal keel vayu ,

Santhigam affected - Produce difficulty in movements of the knee joints.

S.No HUMOUR INCREASE DECREASE

1 Vatham Distended abdomen, Constipation, weakness, Insomnia,tremors, guiddiness, Blackish discoloration of body

Body pain, feeble voice, syncope,diminished capability of brain,

symptoms associated with growth of kabam.

2. Piththam Yellowish discoloration of eyes,Skin, urine and motion, Polyphagia, polydypsia, Burning sensation all over the body, sleeplessness.

Cold, Pallor, Decreased appetite.

3. Kabam Loss of appetite, excessive salivation, heaviness of body, Dyspnoea, excessive

sleeping,

Diminished activity.

Prominence of bone edges, Profuse, palpitation, sweating, Guiddiness, dryness of joints.

VARIATION OF MUKKUTRAMS

Vatham is mainly responsible for proper loco-motor functions. Bones and joints are considered to be the main location of vatha.

In Azhal keel vaayu the vatha kutram is mainly affected followed by pitham and Kabam. This produces the following signs and symptoms,

1. Deranged viyanan leads to pain and difficulty in movements.

2. Deranged Abanan leads to constipation.

3. Inflammatory changes of the joints, redness and warmth are developed due to deranged pitham.

4. Sathaga pitham gets affected hindering the loco motor functions.

5. Along with vatham, kabam is also deranged, i.e Santhikam is affected and this leads to abnormality in joint movements.

6. Erosions of bone margin, increased secretion of synovial fluid are developed due to deranged kabam.

IMPORIGAL:

Gnanenthiriyam are Mei, Vaai, Kan, Mooku and Sevi.

In Azhal keel vaayu no abnormalities are seen in Gnanenthiriyam KANMENTHIRIYAM:

Kanmenthiriyam are Kai, Kaal, Vaai, Eruvaai, Karuvaai.

In Azhal keel vaayu “kaal” is affected and become of pain and swelling, morning stiffness and deformities.

KAALAM

Ancient Tamilians divided a year into six different seasons known as

Perumpozhudhu and likewise the day into six segments which are known as Sirupozhudhu.

Perumpozhudhu:

A year is divided into six seasons. They are as follows

Sl.NO. Season Months Kuttram

1. Kaarkaalam

Aavani & Purattasi August 16 – October 15

Vatham ↑↑

Pitham ↑ 2. Koodhir kaalam

Ayppasi and kaarthigai October 16 – December 15

Vatham (-) Pitham ↑ 3. Munpani kaalam

Margali and Thai December 16 – February 15

Pitham (-)

4. Pinpani kaalam

Maasi and panguni February 16 – April 15

Kabam ↑

5. Elavenir kaalam

Chithirai and Vaigasi April 16 – June 15

Kabam ↑ ↑

6. Mudhuvenir

kaalam

Aani and Aadi June 16 – August 15

Vatham ↑ Kabam (-)

↑ - Thannilai valarchi (-) - Thannilai adaidhal

↑↑ - Vetrunilai valarchi

 In Kaarkalam Vatha diseases may occur greatly.

 In Muthuvenil kaalam it may worsen badly.

NOI KANIPPU VIVATHAM (DIFFERENTIAL DIAGNOSIS):

Azhal keel vaayu is differentiated from the followings diseases, VALI KEEL VAAYU:

.

-

It is characterized by excruciating pain and swelling involving knee joints, hip joints, elbow joints, shoulder joints and associated with systemic disturbances like dryness of mouth, pyrexia, headache, palpitation, constipation and sweating. In advanced cases it may affect the heart and produce “Thamaraga vaayu”.

IYA KEEL VAAYU:

-

It is characterized by severe pain in the joints associated with emaciation of the body, anorexia, insomnia, cough, hiccough, vomiting, anaemia and dropsy. The common sites are spinal cord, hip joints and knee joints.

VALI IYA KEEL VAAYU:

.

-

It is characterized by pain in the joints associated with effusions of joint fluid and swelling, restricted joint movements, pyrexia, fainting, insomnia, especially in knee joint asymmetrically, lymphadenopathy, generalized malaise, atrophy of the affected limb etc. The affected joint looks like “Fox’s Head”

VALI AZHAL KEEL VAYU:

.

-

It is characterized Indigestion,belching, flatulence constipation and increased body weight. Pain and rednesss burning sensation, in wrist , ankle joint, inter phalangeal joints.sleeplessness and fever occurs.

VALI IYA KEELVAYU:

.

. -

It is characterized by Swelling in the both knee joint, pain and pricking sensation in both knee joints, inability to flex and extended upper limb and lower limb. Insomnia, emasiation, lymph adenopathy in axilla, inguinal region, muscular atrophy in affected limbs, swelling of joint resemble fox head.

AZHAL VALI KEEL VAYU

. !

-

It is characterized by joint pain and swelling, inability to flex and extend the knee joint associated with rhinitis throat soareness, sneezing, vomiting body pain fever.

AZHAL IYA KEEL VAYU

. -

This type of keelvayu is associated with veneral disease, in prodormal stage the main symptom is sever head ache, nausea, vomiting, fatigue, body ache.

Then it aggreviate with high body temperature pain and swelling elbow and knee joint, inability to flewxion and extension, later swelling of the joint appearas like fox head, ( it shows its severity.

IYA THEEK KEEL VAYU

. -

This type of keelvayu is Rhinitis, throat soreness, joint pain and swelling, inability to flex and extend the knee joint associated with rhinitis throat soarness, sneezing, vomiting body pain high body temperature..

MUKKUTRA KEEL VAAYU :

! -

It is characterized by Fever , pain, and swelling, swelling increases due to elevated kabam, delirium. if untreated can death occur_.

LINE OF TREATMENT

In Siddha system the main aim of the treatment is to cure Udarpini (due to Mukkuttram) and Manapini (due to changes in Mukkunam). Treatment is not only for perfect healing but also for the prevention and rejuvenation.

It is essential to know the disease, the aetiology, the nature of the patient, severity of the illness, the seasons and the time of occurrence must be observed clearly.

Line of treatment is as follows:

1. Kaapu (Prevention) 2. Neekkam (Treatment) 3. Niraivu (Restoration)

Thiruvalluvar details the duty of the physicians, i.e. study the disease, study the cause, seek subsiding ways and do what is proper and effective.

”

”

( )

1)KAPPU (Prevention):

The prevention methods for Azhal keel vaayu are as follows:

Control the body weight by diet and exercise.

Modify the nature of work which gives stress to a particular joint.

e.g. - Avoid prolonged standing and long distance walking.

Avoid intake excess sour, astringent and bitter tasted foods.

2) NEEKKAM (Treatment in Siddha):

The aim of Neekkam is based on

To bring the deranged Thodams to normal equilibrium state.

To treat the patient with internal medicine and external medicine.

First the deranged vatham has to be brought to its normal state by giving purgation. It is mentioned in the following verse

”

-

1. PURGATIVE:

In Azhal keel vaayu vatha kutram is deranged. So a purgative medicine Agasthiyar kuzhambu - 130 mg with ginger juice was given in early morning in empty stomach on the first day of treatment.

2.INTERNAL MEDICINE:

Sarva noi linga chenduram– 130 mg twice a day given with honey after food.

Ref- Anuboga vaithiya Navaneetham, part 4, pg no 53&54 3. E XTERNAL MEDICINE:

Maasha Thylum [ ulunthu thylum ]

Ref: Vaithiya Sinthamani ( Sigicha Rathina deepam ) Pg no:202

C.Kannusamipillai Edition 2007 4.DIET TO BE ADVISED :

VEGETABLES :Tender brinjal, Tender drumstick, Lablab bean.

LEAVES :Sessile leaves,Black night shade, Hog weed, Climbing brinjal, dog mustard leaves, Curry leaf.

FRUITS :Pomagranate, apple,Dates palm,country fig, Jambul fruit.

NON VEGETARIAN :Goat, prawn fish. And Advised to take milk

4. DIETARY RESTRICTIONS:

‘’

‘’

Mustard, sesame oil. Pumpkin, country arrack, groundnut, coconut, mango, jackfruit,garlic, asofoetida, tobacco, bitter – guard, sesbania leaves, excessive sexual desire.

‘’ ‘’

.

Astringent and sour tastes to be avoided.

Modern Aspects

MODERN ASPECTS OSTEO ARTHRITIS

INTRODUCTION:

Osteoarthritis can be defined as a degenerative, non-inflammatory joint disease characterised by destruction of articular cartilage and formation of new bone at the joint surfaces and margins. However, it is a misnomer and the right term is Osteoarthrosis or degenerative joint disease.

EPIDEMIOLOGY:

Osteoarthritis is by far the most common joint disorder throughout the world, and is one of the leading cause of disability in the elderly. Although the disease commonly affects the cervical and lumbar spine, most epidemiologic studies report that it has a predilection for weight bearing joints in the leg and certain joints in the hand.

The prevalence of osteoarthritis in all joints correlates strikingly with age .One third of people aged 65 years and older have knee osteoarthritis that is evident by radiograph. Before the age 50, men are more likely to have osteoarthritis than women, but after age 50,it is common in women who are more likely to be affected.

Osteoarthritis is already one of the ten most disabling diseases in developed countries.

Farming 1-9 years increases the risk of osteoarthritis 4 times, farming 10 or more years increases the risk 9 times.

World wise estimates are that 10% of men and 18% of women aged over 60 years have symptomatic osteoarthritis.

80% of those with osteoarthritis will have limitations in movement, and 25%

cannot perform their major daily activities of life.

ANATOMY OF THE KNEE JOINT Introduction:

The knee joint is the largest and most complex joint of the body. The complexity is the result of fusion of three joints in one. It is formed by fusion of the lateral femorotibial, medial femorotibial and femoropatellar joints.

Injuries to the knee joint are amongest the most common in sporting activities and understanding the anatomy of the joint is fundamental in understanding any subsequent pathology in the joint.

Type:

It is compound synovial joint, incorporating two condylar joints between the condyles of the femur and tibia, and one saddle joint between the femur and patella

Articular surfaces

The knee joint is formed by

The condyles of the femur The condyles of the tibia and The patella

The femoral condyles articulate with the tibial condyles below and behind, and with the patella in front.

Ligaments

The knee joint is supported by a number of ligaments that are, Fibrous (articular) capsule

Ligamentum patellae

Tibial collateral(medial) ligament Fibular collateral ligament

Oblique popliteal ligament Arcuate popliteal ligament

Cruciate ligaments

Menisci(semilunar cartilages) Transverse ligament

The stability of the knee owes greatly to the presence of its ligaments.

Each has a particular function in helping to maintain optimal knee stability in a variety of different positions.

The knee joint capsule:

The joint capsule is a thick ligamentous structure that surrounds the entire knee. Inside this capsule is a specialized membrane known as the synovial membrane which provides nourishment to all the surrounding structures. Other structures include the infrapatellar fat pad and bursa which function as cushions to exterior forces on the knee. The capsule itself is strengthened by the surrounding ligaments.

Menisci (semi lunar cartilages)

The menisci are two fibro cartilaginous discs.They are shaped like crescents. They deepen the articular surfaces of the condyles of the tibia and partially divide the joint cavity into the upper and lower compartments.

Functions of menisci

They help to make the articular surfaces more congruent The menisci serve as shock absorbers

They help to lubricate the joint cavity

Because of their nerve supply, they also have a sensory function. They give rise to proprioceptive impulses.

Synovial fluid

Synovial fluid is a thick, stringy fluid found in the cavities of synovial joints.With its egg like consistency(synovial comes from latin for “egg”), synovial fluid reduces friction between the articular cartilage and other tissues in joints to lubricate and cushion them during movements.

Muscle groups surrounding the knee joint:

The two main muscle groups of the knee joint are the quadriceps and the hamstrings. Both play a vital role, both moving and stabilizing the knee joint.

Quadriceps muscle:

The quadriceps muscle group is made up of four different individual muscles which join together forming the quadriceps tendon. This thick tendon connects the muscle to the patella which in turn connects to the tibia via the patellar tendon. Contraction of the quadriceps, pull the patella upwards and leads to knee extension.

Hamstrings muscle:

The Hamstrings muscle function is flexing the knee joint as well as providing stability on either side of the joint line.

Movement

Flexion Extension Medial rotation Lateral rotation

Flexion and extension are the chief movements. Those take place in the upper compartment of the joint above the menisci.

Rotatory movements at the knee are of a small range. Rotations take place around a vertical axis, and are permitted in the lower compartment of the joint, below the menisci.

Blood supply:

The knee joint is supplied by the anastomosis around it. The chief sources are Five genicular branches of the popliteal artery

The descending genicular branch of the femoral artery

The descending branch of the lateral circumflex femoral artery Two recurrent branches of the anterior tibial artery

The circumflex fibular branch of the posterior tibial artery

Nerve supply

Femoral nerve Sciatic nerve Obturator nerve

LIGAMENTS OF THE KNEE JOINT

LOCATION OF PAIN

MUSCLES OF THE KNEE

AETIOLOGY:

PRIMARY CAUSE OF OSTEOARTHRITIS:

Though exact cause is not known, the following factors are suspected to play an important role in the causation of primary osteoarthritis

1) Endocrine 2) Post Traumatic

3) Inflammatory joint disease 4) Metabolic

5) Congenital or developmental 6) Genetic

7) Neuropathic and others

1

People with Diabetes may be prone to osteoarthritis. Other endocrine problems also may promote development, including Acromegaly, Hypothyroidism, Hyper parathyroidism and Obesity.

2.

Traumatic causes can be further divided into macro trauma or micro trauma. An example of macro trauma is an injury to the joint such as bone break causing the bones to line up improperly (mal alignment), lose of stability or damage cartilage. Micro trauma may occur over time (chronically). An example of this would be repetitive movements or the overuse noted in several occupations.

3.

This category would include infected joints, chronic gouty arthritis and rheumatoid disease.

4

Disease causing errors of metabolism may cause osteoarthritis.

Examples include Paget’s disease and Wilson’s disease.

5.

Abnormal anatomy such as unequal length of legs may be a cause of osteoarthritis.

6.

A genetic defect may promote breakdown of the protective architecture of cartilage. Examples include collagen disturbances such as Ehlers- Danlos Syndrome.

7. NEUROPATHIC:

Diseases such as Diabetes can cause nerve problems. It may affect the the Joints and limbs.

8

Nutritional problems may cause osteoarthritis. Other disease such as haemophilia and sickle cell anaemia are further examples.

SECONDARY CAUSES OF OSTEO ARTHRITIS:

The causes for secondary osteoarthritis of the knee are as follows:

Obesity

Valgus and varus deformities of the knee.

Intra – articular fractures of the knee, etc.

Rheumatoid arthritis, infection, trauma, TB, etc.

Hyper parathyroidism.

Haemophilia.

Syringomyelia

Overuse of intra- articular steroid therapy.

It is generally observed that secondary osteoarthritis occurs in the younger age groups and is more severe than the primary. Apart from all the features of osteoarthritis, secondary osteoarthritis has the features of the corresponding aetiological condition.

CLASSIFICATIONS:

It could be divided into 2 types

1. Primary or idiopathic osteoarthritis 2. Secondary osteoarthritis

Primary osteo arthritis results from changes caused by specific inflammatory or metabolic conditions while secondary osteo arthritis is caused by other conditions that damage cartilage.

PATHOGENESIS:

PRIMARY OSTEOARTHRITIS SECONDARY OSTEOARTHRITIS 1.Usually limited to one or a small

number of joints.

May be limited to a small number of joints if injury related or may be in joints throughout body, if disease related

2.No specific inflammatory or metabolic condition known to be associated with arthritis is present.

Condition that cause damage to cartilage are present, such as -

Inherited disease of iron, calcium or copper storage such as

haemochromatosis,

Hyperparathyroidism or Wilson’s disease.

Neurologic disorder that result in the loss of nerve function.

Congenital disease that cause an imbalance in the joints.

3.No history of specific injury or trauma.

History of injury to joints, such as fractures and tears or history of trauma to joints, such as repetitive heavy lifting.

NORMAL ARTICULAR CARTILAGE:

Normal cartilage has two main components. One is the extra cellular matrix, which is rich in collagens (mainly types II, IX and XI) and proteoglycans IX mainly aggrecan. Aggrecan is a central core protein bearing numerous glycosaminoglycans chains of chondroitin sulphate and keratin sulphate, all capable of retaining water.

The second component consists of isolated chondrocytes, which lie in the matrix. The matrix component is responsible for the tensile strength and resistance to mechanical loading of the articular cartilage.

PASSAGE OF NORMAL CARTILAGE TO AGING CARTILAGE:

Several structural and biochemical changes involving the non collagenous component of the matrix occur during aging. These changes alter biochemical properties of the cartilage that are essential for the distribution of forces in the weight bearing zone.

Glycosamino glycans are modified qualitatively, they become shorter as the cartilage ages.The concentration of type VI keratin sulphate increase during aging, to the determent of type IV keratin sulphate.

These quantitative and qualitative changes in proteoglycan reduce the capacity of the molecules to retain water. Thus aging cartilage contains less water, which alters the biochemical properties of the cartilage.

OSTEOARTHRITIC JOINTS

Osteoarthritic joints have abnormal cartilage and bone, with synovial and capsular lesions.

Macroscopically the most characteristic elements are, Reduced joint space.

Formation of osteophytes(protrusion of bone and cartilage) mostly at the margins of joints.

Sclerosis of the subchondral bone

SIGNS AND SYMPTOMS:

The most common signs and symptoms of osteoarthritis are;

Predominant symptom is pain which decreases on walking. The pain is poorly localised and dull aching in nature.

The patient complains of early morning stiffness which subsides over the day after activity.

Morning stiffness, which usually lasts no more than 30 minutes.

Swelling of the joints Minimal tenderness

Restricted range of joint movements Coarse crepitus can be elicited

SITES:

Common sites of primary osteoarthritis:

Apophyseal joint of the cervical spine Thoraco lumbar spine

First carpometacarpal joint Distal interphalangeal joint Patella femoral joint Tibio femoral joint

First metatarsalphalangeal joint

Intermediate sites:

Acromio clavicular joint Hip joint

Uncommon sites:

Shoulder joint Elbow joint Wrist joint

Metaphalangeal joint Ankle joint

DIAGNOSTIC CRITERIA:

Formal criteria helpful for diagnosis of osteoarthritis in synovial joints:

Age greater than 60 years.

Pain and swelling in knee joint

Morning stiffness lasting less than 30 minutes.

Crackling sensation (crepitus) present in knee joint.

Joint- line or periarticular tenderness.

Bony swelling (osteophyte) around joint margins.

Restricted joint movements DIAGNOSIS:

There is no single sign, symptom or test result that allows a definitive diagnosis of osteoarthritis. Instead the diagnosis is based on a consideration of several factors, including the presence of the characteristic signs and symptoms of osteoarthritis, physical examination and the results of laboratory tests and x-rays.

COMPLICATIONS OF OSTEOARTHRITIS:

The major complications of osteoarthritis of knee Joint deformities

Subluxation Ankylosis

Intra- articular loose bodies Life style effects include

Depression Anxiety

Feelings of helplessness Limitation of daily activities Job limitations

PROPERTIES OF

TRIAL DRUGS

– NATURAL RED SULPHIDE OF MERCURY

(Cinnabar)

Potency- Hot

Action - ( Alterative ) General Properties

– ’’

– ’’

-

Uses:

It cures diarrhoea, pyrexia, delirium, urticaria, tuberculosis, scabies, insect bites, syphilis, skin diseases, throbbing pain(soolai) and vatha diseases.

- SODIUM BIBORATE Action:

Refrigerant Diuretic Emmenagogue Lithontriptic Antiseptic Taste: Sweet With Astringent General Properties

- .

-

Vengaram is indicated for eight type of ulcers, dental diseases, urinary tract infections, kabha disorders, delirium.